Basic Information
| Provider Information | |||||||||
| NPI: | 1740782465 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCONACHIE | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | SLP-CCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 S AVE K | ||||||||
| Address2: | STATION 3, SHROC | ||||||||
| City: | PORTALES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88130 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1628 19TH ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794014832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062190500 | ||||||||
| FaxNumber: | 8067661286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2018 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 235Z00000X | 117355 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.